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Despite a common CD4+ T-cell precursor, helper T (Th) 1 and 2 lymphocytes affect different immunologic responses, including cellular and humoral pathways, respectively. Th1 cells stimulate the activation of type 1 macrophages, IgG/immunoglobulin M production, and cytokine release (eg, interferon gamma [IFN-γ], interleukin 2) to respond to intracellular pathogens. In contrast, Th2 cells target extracellular pathogens, leading to increases in immunoglobulin E and proliferation of eosinophils, basophils, B lymphocytes, type 2 macrophages, and mast cells through the actions of interleukin 4 (IL-4), interleukin 5, interleukin 13 (IL-13), and interleukin 31.1 Th17 cells are important for host defense against extracellular bacteria and fungi, as well as injury, and are thought to be key drivers of autoimmune diseases. Th17 cells produce interleukin 17A, interleukin 17F, interleukin 22, and C-C motif chemokine ligand 20 and are characterized by neutrophil and macrophage recruitment. The Th2 cytokine, IL-4, has been shown to inhibit Th17 development.2 Dupilumab (Dupixent, Regeneron Pharmaceuticals and Sanofi Genzyme), a fully human monoclonal (IgG4) antibody, inhibits the signaling of IL-4/13 by blocking the shared receptor subunit, IL-4 receptor α. Dupilumab is an effective treatment for a number of Th2-driven conditions, including atopic dermatitis (AD), asthma, and chronic rhinosinusitis with nasal polyposis. Multiple sclerosis (MS) is an inflammatory disease of the central nervous system, which is characterized by multifocal demyelination and neuroaxonal degeneration, where the immune system is skewed toward Th1/Th17 axes.3 Interestingly, epidemiologic studies have suggested that a history of allergic diseases may confer some protection from MS.4 We report a temporal association of relapsing-remitting MS flareup and dupilumab treatment for AD. We provide a potential mechanism by which dupilumab leads to Th2 suppression with secondary Th1/17 dysregulation.

BACKGROUND Hypernatremia is one of the most common electrolyte disturbances following aneurysmal subarachnoid hemorrhage (aSAH) and has been correlated with increased mortality in single institution studies. We investigated this association using a large nationwide healthcare database. METHODS We performed a retrospective analysis of adults between 2002 and 2011 with a primary diagnosis of aSAH using the Nationwide Inpatient Sample (NIS). Patients were grouped according to whether or not an inpatient diagnosis of hypernatremia was present. The primary outcome was the NIS-SAH outcome measure. Secondary outcomes included in-hospital mortality, length of stay (LOS), and non-routine hospital discharge. Outcomes analyses adjusted for SAH severity using the NIS-SAH Severity Score, Charlson Comorbidity Index, and the presence of cerebral edema. RESULTS A total of 18,377 patients were included in the study. The incidence of a poor outcome as defined by the NIS-SAH outcome measure was 65.9% in the hypernatremia group and 33.4% in the normonatremia group (OR=1.96, 95% CI: 1.68-2.27). There was higher mortality in the hypernatremia group (OR=1.60, 95% CI: 1.37-1.87). Patients with hypernatremia had a significantly higher rate of non-routine hospital discharge and gastrostomy. The incidences of poor outcome, in-hospital mortality, and non-routine disposition were higher in the hypernatremia group regardless of treatment type (clipping vs. endovascular embolization). Pulmonary complications and acute kidney injury were more common in the hypernatremia group as well. CONCLUSIONS In patients with aSAH, hypernatremia is associated with poorer functional outcomes regardless of SAH severity.

Primary mucinous carcinoma (PMC) is a rare adnexal neoplasm derived from sweat glands.1 To our knowledge, there has been a single case of ipsilateral and 2 cases of bilateral multifocal PMC of the eyelids reported in the literature.2, 3, 4 In both bilateral cases, the second malignant lesion was discovered following excision of the original carcinoma. We present a very rare case of multifocal PMC presenting with 3 tumors on the ipsilateral upper and lower eyelids and discuss considerations in management.

Background: Cortical bone trajectory (CBT) screws are an alternative to traditional pedicle screws (PS) for lumbar fixation. The proposed benefits of CBT screws include decreased approach-related morbidity and greater cortical bone contact to prevent screw pullout. Relatively little data is published on this technique. Here, we compare the midline lumbar fusion (MIDLF) approach for CBT screw placement to transforaminal lumbar interbody fusion (TLIF) for traditional PS placement. Methods: A prospectively maintained institutional database was retrospectively reviewed for all patients undergoing lumbar spinal fusion using CBT screws over the past 5 years. Controls were identified from the same database as patients undergoing lumbar spinal fusion with traditional PS placement and matched based on age, sex, and number of levels fused. Exclusion criteria included prior lumbar instrumentation. The electronic health record was retrospectively reviewed for demographic, perioperative, and postoperative data. Results: A total of 23 patients who underwent CBT screw placement and 35 controls who received traditional PS were included in the study. The median follow-up time was 52.5 months. The CBT screw group had significantly less mean estimated blood loss than the PS group (186 mL versus 414 mL respectively; P = .008). Both groups experienced significant improvements in preoperative Oswestry Disability Index (ODI) and visual analog scale (VAS) scores for back and leg pain. However, there was no significant difference between the groups in regard to operative time and amount of improvement in VAS pain score or ODI. The CBT group was associated with a significantly shorter mean length of stay (LOS). There were 2 instances of screw pullout in each group. Conclusions: The MIDLF approach with CBT screw placement is associated with less intraoperative blood loss and shorter LOS than traditional PS placement. There is no difference between the 2 techniques in regard to improvement in pain or disability.

Chronic subdural hematoma (cSDH) is a common condition that disproportionately affects older patients. Given the greater risks of general anesthesia in this population, interest has turned towards less invasive surgical approaches such as the subdural evacuating port system (SEPS; Medtronic, Inc., Minneapolis, MN). There is a relative dearth of information about the outcomes following this procedure. Here, we present our institution’s experience with SEPS and analyze factors associated with the outcomes. Using a prospectively maintained institutional database, we retrospectively identified all patients who presented with cSDH and received first line therapy with SEPS. Pre- and post-operative clinical and radiographic data was obtained from the electronic health record. Outcomes included success or failure, Modified Rankin Scale (mRS) at discharge, length of stay (LOS), and discharge disposition. A total of 126 patients met the inclusion criteria (36 females and 90 males; mean age of 71.6 years). None of the pre-procedural clinical or radiographic variables were associated with the likelihood of a successful outcome. Increasing age was associated with non-routine hospital discharge (p = 0.003), and lower presenting GCS was associated with longer hospital stay (p = 0.005). Greater thickness of the cSDH was associated with a lower likelihood of having a favorable outcome (mRS ≥ 3; p = 0.003). SEPS is an effective first-line therapy for cSDH. Variables previously reported to limit the effectiveness of the technique (presence of septations, mixed density collections) were not associated with treatment failure.

Here, we present a case of arsenic-induced Bowen’s disease treated with a regimen consisting of topical 5-fluouracil and oral nicotinamide. The use of this therapy modality resulted in near complete resolution of all of the patient’s lesions except for those on her palms, soles, and scalp. Excellent wound care and treatment adherence were major factors contributing to the success of this treatment option. Our results ultimately provide an alternative approach to treating multiple arsenical keratoses in patients who are limited to a drug plan involving 5-FU and oral nicotinamide and who are able to be rigorously compliant with application of medication and wound care. J Drugs Dermatol. 2019;18(5):477-479.